The National Transportation Safety Board today heard the results of a thorough investigation, and concluded that both Conrail and Paulsboro bear much of the blame.

“I think the emergency response for this derailment was, in one word — abysmal,” said Robert L. Sumwalt.

The bridge had been having problems with its lock system, which keeps the rails aligned.

It had malfunctioned 11 times the month before the accident, and a consultant advised Conrail the day before to stop using the bridge in it’s normal fashion.

Among the NTSB findings: the Conrail conductor who stopped his train to inspect the bridge before crossing it was inadequately trained on moveable bridges.

“This conductor basically had no clue,” said Mark R. Rosekind.

The town of Paulsboro was two years overdue in filing an updated emergency operation plan with the state. Paulsboro officials advised residents after the accident to stay in their homes in the mistaken belief the train was carrying liquified natural gas, not the more hazardous vinyl chloride; and neither Conrail nor Paulsboro made sure the community was familiar with the hazardous materials routinely transported through the town.

“Maybe in days past, the probable cause would have been drafted to say the conductor’s failure to properly assess the bridge and make sure it was sound or whatever but I very much like that we’ve hit this systemic level of this. We’ve talked about the failure of Conrail,” said Sumwalt.

According to the NTSB, 28 Paulsboro residents and 20 first responders required hospital treatment.

Thirty million dollars was spent on response and remediation, not counting lawsuits.

The mayor of Paulsboro welcomed the findings today and added his own critique.

“Through it all there was a lack of communication between all the forces that were out there. Everybody wanted to take control and everybody wants to be a chief, was nobody, no Indian,” said Paulsboro Mayor W. Jeffery Hamilton.

A spokesman for Conrail said, “We regret this incident, take seriously the NTSB’s findings and have redoubled our efforts to work with first responders.”

About three dozen people worked on the investigation. The five NTSB board members approved all 23 recommendations made today. One of them said accidents like these are always organized chaos, but on this day it was just chaos without the organization.